Advanced Life Support Units Research Articles

Clinical phenotypes and short-term outcomes based on prehospital point-of-care testing and on-scene vital signs

Emergency medical services (EMSs) face critical situations that require patient risk classification based on analytical and vital signs. We aimed to establish clustering-derived phenotypes based on prehospital analytical and vital signs that allow risk stratification. This was a prospective, multicenter, EMS-delivered, ambulance-based cohort study considering six advanced life support units, 38 basic life support units, and four tertiary hospitals in Spain. Adults with unselected acute diseases managed by the EMS and evacuated with discharge priority to emergency departments were considered between January 1, 2020, and June 30, 2023. Prehospital point-of-care testing and on-scene vital signs were used for the unsupervised machine learning method (clustering) to determine the phenotypes. Then phenotypes were compared with the primary outcome (cumulative mortality (all-cause) at 2, 7, and 30 days). A total of 7909 patients were included. The median (IQR) age was 64 (51–80) years, 41% were women, and 26% were living in rural areas. Three clusters were identified: alpha 16.2% (1281 patients), beta 28.8% (2279), and gamma 55% (4349). The mortality rates for alpha, beta and gamma at 2 days were 18.6%, 4.1%, and 0.8%, respectively; at 7 days, were 24.7%, 6.2%, and 1.7%; and at 30 days, were 33%, 10.2%, and 3.2%, respectively. Based on standard vital signs and blood test biomarkers in the prehospital scenario, three clusters were identified: alpha (high-risk), beta and gamma (medium- and low-risk, respectively). This permits the EMS system to quickly identify patients who are potentially compromised and to proactively implement the necessary interventions.

A Qualitative Analysis of Barriers to Evidence-Based Care in the Prehospital Management of Patients with Suspected Acute Coronary Syndrome

Objectives Prehospital electrocardiogram (ECG) and administration of aspirin are evidence-based strategies for patients with acute coronary syndrome (ACS). However, emergency medical services (EMS) compliance in patients with suspected ACS varies widely. We sought to understand the barriers to prehospital ECG acquisition and aspirin administration for patients with suspected ACS. Methods In this qualitative study, we interviewed EMS clinicians at three geographically diverse United States (U.S.)-based EMS agencies. We interviewed practicing clinicians and quality and operations leaders at these agencies. Based on the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, interviews were recorded, transcribed, and analyzed using a grounded qualitative approach with open coding. The Systems Engineering Initiative for Patient Safety (SEIPS) framework and a constant comparison technique were used to identify and refine themes. Results Twenty-five paramedics and 20 additional agency personnel participated. Median age was 41 (IQR: 34–51) years and 13 (29%) were female. Themes were organized using SEIPS and longitudinally through four phases of an EMS call. During the pre-arrival phase, staffing challenges, training quality, and dispatch may anchor EMS clinicians on a diagnosis. During the diagnosis and treatment phase, safety and communication barriers may take priority over care delivery. Additionally, EMS clinicians must allocate assets (e.g. whether to send an advanced life support unit) and financial resources; veteran EMS clinicians identified their experience whereas newer clinicians cited their recent education when making these decisions. Also, diagnostic uncertainty due to increasing patient complexity and atypical presentations contributed to diagnostic errors. During the response and transport phase, the scope of practice limits the use and interpretation of the ECG, with clinicians reporting that liberal use of ECG led to more rapid decision-making. Finally, in the after phase, personnel reported the “psychologically taxing” nature of the job contributing to biases, bad habits, and burnout. Performance feedback was desired for personal development, though currently perceived as infrequent and punitive. Conclusions Multiple, interrelated themes underscored the complexities of delivering evidence-based care to prehospital patients with ACS. Education in ECG interpretation, resource allocation, bias, and enhancing feedback may serve as strategies to address the identified barriers.

Incorporation of age into patient early warning scores significantly improves mortality prediction.

Age is a critical factor for the assessment of patients attended by emergency medical services (EMSs). However, how age modifies early warning scores' (EWSs) predictive ability should be unveiled. To determine how age influences the performance of EWS [National Early Warning Score 2 (NEWS2), VitalPAC-Early Warning Score (ViEWS), Rapid Acute Physiology Score (RAPS) and modified Rapid Emergency Medicine Score (mREMS)] to predict 2-day mortality. The secondary objective was to determine the performance of EWSs at different age ranges. A prospective, observational study performed between November 2019 and July 2023. A multicenter, ambulance-based study, considering 38 basic life support units and six advanced life support units referring to four tertiary care hospitals. Eligible patients were adults recruited from among all phone requests for emergency assistance who were later evacuated to emergency departments. The primary outcome was 2-day in-hospital mortality (includes all-cause mortality). The main measures were demographical and vital signs needed for EWS calculation. A total of 8028 participants fulfilled the inclusion criteria, with 7654 survivors and 374 non-survivors. Among age ranges, the 2-day mortality was 2.8% for the ≤44 years, 3.3% for the 45-64 years, 4.1% for the 65-74 years and 6.7% for the ≥75-year age group. The inclusion of age significantly improved the Area Under the Curve (AUC) in all the scores (P = 0.006 for non-age-adjusted mREMS, P = 0.001 for NEWS2, P = 0.002 for ViEWS, P = 0.028 for RAPS, all compared with their counterparts with age). Our results demonstrated that the incorporation of age into the EWS improved the performance of the scores. These results will allow the EMS to improve patient management and resource optimization by including an easy-to-obtain variable.

Epidemiology, use, and practice of the intraosseous route in an out-of-hospital emergency department: a retrospective cross-sectional study.

The Spanish Emergency Medical Services, according to the model we know today, were formed during the 80s and 90s of the 20th century. The Health Emergency Service (EMS), 061 La Rioja, began to assist the population of La Rioja in November 1999. An essential part of the mission of the SES is the provision of care and the transfer of critical patients using advanced life support unit (ALSU) techniques. In daily practice, out-of-hospital emergency services are faced with situations in which they must deal with the care of serious or critically ill patients, in which the possibility of being able to channel peripheral vascular access as part of ALSU quickly may be difficult or impossible. In these cases, cannulation of intraosseous (IO) vascular access may be the key to early and adequate care. This study aimed to determine the incidence and epidemiology use of IO vascular access in SES 061 La Rioja during the year 2022. We performed observational retrospective cross-sectional studies conducted in 2022. It included a population of 4.364 possible patients as a total of interventions in the community of La Rioja in that year. A total of 0.66% of patients showed a clinical situation that required the establishment of IO vascular access to enable out-of-hospital stabilization; this objective was achieved in 41.3%. A total of 26.1% of patients who presented with cardiorespiratory arrest (CA) were stabilized, while 100% presented with shock and severe trauma. IO vascular access provides a suitable route for out-of-hospital stabilization of critically ill patients when peripheral vascular access is difficult or impossible.

Prehospital lactate-glucose interaction in acute life-threatening illnesses: metabolic response and short-term mortality.

Lactate is an already recognized biomarker for short-term mortality. However, how glycemia and diabetes affect the predictive ability of lactate needs to be revealed. To determine how hypoglycemia, normoglycemia, and hyperglycemia modify the predictive ability of lactate for short-term mortality (3 days). The secondary objective was to evaluate the predictive ability of lactate in diabetic patients. Prospective, observational study performed between 26 October 2018 and 31 December 2022. Multicenter, EMS-delivery, ambulance-based study, considering 38 basic life support units and 5 advanced life support units referring to four tertiary care hospitals (Spain). Eligible patients were adults recruited from among all phone requests for emergency assistance who were later evacuated to emergency departments. The primary outcome was in-hospital mortality from any cause within the third day following EMS attendance. The main predictors considered were lactate, blood glucose levels and previous diabetes. A total of 6341 participants fulfilled the inclusion criteria. 68 years (IQR: 51-80); 41.4% were female. The 3-day in-hospital mortality rate was 3.5%. The predictive capacity of lactate for 3-day mortality was only significantly different between normo-glycemia and hyperglycemia. The best predictive result was for normo-glycemia - AUC = 0.897 (95% CI: 0.881-0.913) - then hyperglycemia - AUC = 0.819 (95% CI: 0.770-0.868) and finally, hypoglycemia - AUC = 0.703 (95% CI: 0.422-0.983). The stratification according to diabetes presented no statistically significant difference, and the predictive results were AUC = 0.924 (95% CI: 0.892-0.956), AUC = 0.906 (95% CI: 0.884-0.928), and AUC = 0.872 (95% CI: 0.817-0.927) for nondiabetes, uncomplicated cases, and end-organ damage diabetes, respectively. Our results demonstrated that glycemia, but not diabetes, alters the predictive ability of lactate. Therefore, hyperglycemia should be considered when interpreting lactate, since this could improve screening to detect cryptic shock conditions.

Race and Ethnicity and Prehospital Use of Opioid or Ketamine Analgesia in Acute Traumatic Injury

Racial and ethnic disparities in pain management have been characterized in many hospital-based settings. Painful traumatic injuries are a common reason for 911 activations of the EMS (emergency medical services) system. To evaluate whether, among patients treated by EMS with traumatic injuries, race and ethnicity are associated with either disparate recording of pain scores or disparate administration of analgesia when a high pain score is recorded. This cohort study included interactions from 2019 to 2021 for US patients ages 14 to 99 years who had experienced painful acute traumatic injuries and were treated and transported by an advanced life support unit following the activation of the 911 EMS system. The data were analyzed in January 2023. Acute painful traumatic injuries including burns. Outcomes were the recording of a pain score and the administration of a nonoral opioid or ketamine. The study cohort included 4 781 396 EMS activations for acute traumatic injury, with a median (IQR) patient age of 59 (35-78) years (2 497 053 female [52.2%]; 31 266 American Indian or Alaskan Native [0.7%]; 59 713 Asian [1.2%]; 742 931 Black [15.5%], 411 934 Hispanic or Latino [8.6%], 10 747 Native Hawaiian or other Pacific Islander [0.2%]; 2 764 499 White [57.8%]; 16 161 multiple races [0.3%]). The analysis showed that race and ethnicity was associated with the likelihood of having a pain score recorded. Compared with White patients, American Indian and Alaskan Native patients had the lowest adjusted odds ratio (AOR) of having a pain score recorded (AOR, 0.74; 95% CI, 0.71-0.76). Among patients for whom a high pain score was recorded (between 7 and 10 out of 10), Black patients were about half as likely to receive opioid or ketamine analgesia as White patients (AOR, 0.53; 95% CI, 0.52-0.54) despite having a pain score recorded almost as frequently as White patients. In this nationwide study of patients treated by EMS for acute traumatic injuries, patients from racial or ethnic minority groups were less likely to have a pain score recorded, with Native American and Alaskan Natives the least likely to have a pain score recorded. Among patients with a high pain score, patients from racial and ethnic minority groups were also significantly less likely to receive opioid or ketamine analgesia treatment, with Black patients having the lowest adjusted odds of receiving these treatments.

Improving EMS response times for out-of-hospital cardiac arrest in urban areas using drone-like vertical take-off and landing air ambulances: An international, simulation-based cohort study

BackgroundAdvances in vertical take-off and landing (VTOL) technologies may enable drone-like crewed air ambulances to rapidly respond to out-of-hospital cardiac arrest (OHCA) in urban areas. We estimated the impact of incorporating VTOL air ambulances on OHCA response intervals in two large urban centres in France and Canada. MethodsWe included adult OHCAs occurring between Jan. 2017–Dec. 2018 within Greater Paris in France and Metro Vancouver in Canada. Both regions utilize tiered OHCA response with basic (BLS)- and advanced life support (ALS)-capable units. We simulated incorporating 1–2 ALS-capable VTOL air ambulances dedicated to OHCA response in each study region, and computed time intervals from call reception by emergency medical services (EMS) to arrival of the: (1) first ALS unit (“call-to-ALS arrival interval”); and (2) first EMS unit (“call-to-first EMS arrival interval”). ResultsThere were 6,217 OHCAs included during the study period (3,760 in Greater Paris and 2,457 in Metro Vancouver). Historical median call-to-ALS arrival intervals were 21 min [IQR 16–29] in Greater Paris and 12 min [IQR 9–17] in Metro Vancouver, while median call-to-first EMS arrival intervals were 11 min [IQR 8–14] and 7 min [IQR 5–8] respectively. Incorporating 1–2 VTOL air ambulances improved median call-to-ALS arrival intervals to 7–9 min and call-to-first EMS arrival intervals to 6–8 min in both study regions (all P < 0.001). ConclusionVTOL air ambulances dedicated to OHCA response may improve EMS response intervals, with substantial improvements in ALS response metrics.

Effect of the COVID-19 pandemic on advanced life support units’ prehospital management of the stroke code in four Spanish regions: an observational study

IntroductionStroke is the most common time-dependent pathology that pre-hospital emergency medical services (EMS) are confronted with. Prioritisation of ambulance dispatch, initial actions and early pre-notification have a major impact on mortality and disability. The COVID-19 pandemic has led to disruptions in the operation of EMS due to the implementation of self-protection measures and increased demand for care. It is crucial to evaluate what has happened to draw the necessary conclusions and propose changes to improve the system’s strength for the future. The study aims to compare prehospital time and neuroprotective care metrics for acute stroke patients during the first wave of COVID-19 and the same periods in the years before and after.MethodsAnalytical, observational, multicentre study conducted in the autonomous communities of Andalusia, Catalonia, Galicia, and Madrid in the pre-COVID-19 (2019), “first wave” of COVID-19 (2020) and post-COVID-19 (2021) periods. Consecutive non-randomized sampling. Descriptive statistical analysis and hypothesis testing to compare the three time periods, with two by two post-hoc comparisons, and multivariate analysis.ResultsA total of 1,709 patients were analysed. During 2020 there was a significant increase in attendance time of 1.8 min compared to 2019, which was not recovered in 2021. The time of symptom onset was recorded in 82.8% of cases, and 83.3% of patients were referred to specialized stroke centres. Neuroprotective measures (airway, blood glucose, temperature, and blood pressure) were performed in 43.6% of patients.ConclusionDuring the first wave of COVID-19, the on-scene times of pre-hospital emergency teams increased while keeping the same levels of neuroprotection measures as in the previous and subsequent years. It shows the resilience of EMS under challenging circumstances such as those experienced during the pandemic.

Prehospital mSOFA Score for Quick Prediction of Life-Saving Interventions and Mortality in Trauma Patients: A Prospective, Multicenter, Ambulance-based, Cohort Study.

Background: Prehospital emergency medical services (EMS) are the main gateway for trauma patients. Recent advances in point-of-care testing and the development of early warning scores have allowed EMS to improve patient classification. We aimed to identify patients presenting with major trauma involving life-saving interventions (LSI) using the modified Sequential Organ Failure Assessment (mSOFA) score in the prehospital scenario, and to compare these results with those of other trauma scores. Methods: This was a prospective, ambulance-based, multicenter, training-validation study in trauma patients who were treated in a prehospital setting and subsequently transported to a hospital. The study involved six Advanced Life Support units, 38 Basic Life Support units, and four hospitals. The primary outcome was LSI performed at the scene or en route and intensive care unit (ICU) admission and all-cause two-day in-hospital mortality. We collected epidemiological variables, creatinine, lactate, base excess, international normalized ratio, and vital signs. Discriminative power (area under the receiver operating characteristic curve [AUC]), calibration (observed vs predicted outcome agreement), and decision-curve analysis (DCA, clinical utility) were used to assess the reliability of the mSOFA in comparison to other scores. Results: Between January 1, 2020-April 30, 2022, a total of 763 patients were selected. The mSOFA score's AUC was 0.927 (95% confidence interval [CI] 0.898-0.957) for LSI, 0.845 (95% CI 0.808-0.882) for ICU admission, and 0.979 (95% CI 0.966-0.991) for two-day mortality. Conclusion: The mSOFA score outperformed the other scores, allowing a quick identification of high-risk patients. The routine implementation in EMS of mSOFA could provide critical support in the decision-making process in time-dependent trauma injuries.

Outcomes after Clinical and Traumatic Out-of-Hospital Cardiac Arrest.

Data on out-of-hospital cardiac arrest are still scarce, very varied, and indicate a poor prognosis for traumatic events. To describe the out-of-hospital/in-hospital survival, survival time, and neurological conditions of those treated by advanced life support units and submitted to cardiopulmonary resuscitation and compare the results of clinical and traumatic cardiac arrests. This is a cohort study carried out in three stages; in the first two, data were collected from the Mobile Emergency Care Service forms and medical records; then, the Brain Performance Category Scale was applied in the third stage. The sample consisted of resuscitated victims aged ≥18 years. Fisher's and log-rank tests were used to compare the causes, considering a significance level of 5%. 852 patients were analyzed; 20.66% were hospitalized, 4.23% survived until transfer or discharge, and 58.33% had a favorable outcome one year after arrest. There was an association between pre/in-hospital survival and the nature of the occurrence (p=0.026), but there was no difference between the survival curves (p=0.6). Survival of hospitalization after out-of-hospital cardiac arrest was low; however, most who survived to be discharged achieved a favorable outcome after one year. The survival time of those hospitalized after clinical and traumatic events were similar, but pre-hospital survival was higher among trauma patients.

Association between prehospital lactate categories with short- and long-term mortality. A prospective, observational multicenter study.

Lactate is an already recognized biomarker for short-term mortality in emergency medical services (EMS). However, how different levels of lactate associate to short-, mid-, and long-term outcome should be unveiled. To determine how different categories of hyperlactatemia associate to mortality. And to clinically characterize hyperlactatemia groups. Multicenter, prospective, observational study performed between January 2019 and February 2022, considering 48 basic life support units and five advanced life support units referring to four tertiary care hospitals (Spain). Patients were recruited from phone requests for emergency assistance in adults, evacuated to emergency departments. The primary outcome was in-hospital mortality from any cause within the first to the 365 day following EMS attendance. The main measures were demographical and biochemical variables, prehospital advanced life support techniques used, and patient condition categorized in 24 diseases. Univariate and Cox regression analysis. A total of 5,072 participants fulfilled inclusion criteria. Group#1 (non-hyperlactatemia) was composed of 2389 subjects (47.1%), group#2 (mild hyperlactatemia) of 1834 (36.1%), group#3 (hyperlactatemia) of 333 (6.6%), and finally group#4 (severe hyperlactatemia) of 516 (10.2%). The 1-day mortality was 0.2%, 1.1%, 9% and 22.3% in the four lactate groups, respectively. Long-term mortality (365-day) was 10.2%, 22.7%, 38.7% and 46.7% in the four lactate groups, respectively. Differences between patients' conditions of lactatemia groups was also found. Our results demonstrated that prehospital lactate categories were associate to short and long-term in a different manner. These results will allow EMS to establish different risk states according to the prehospital lactate categories.

Prehospital seizures: Short-term outcomes and risk stratification based in point-of-care testing.

Information for treatment or hospital derivation of prehospital seizures is limited, impairing patient condition and hindering patients risk assessment by the emergency medical services (EMS). This study aimed to determine the associated factors to clinical impairment, and secondarily, to determine risk factors associated to cumulative in-hospital mortality at 2, 7 and 30 days, in patients presenting prehospital seizures. Prospective, multicentre, EMS-delivery study involving adult subjects with prehospital seizures, including five advanced life support units, 27 basic life support units and four emergency departments in Spain. All bedside variables: including demographic, standard vital signs, prehospital laboratory tests and presence of intoxication or traumatic brain injury (TBI), were analysed to construct a risk model using binary logistic regression and internal validation methods. A total of 517 patients were considered. Clinical impairment was present in 14.9%, and cumulative in-hospital mortality at 2, 7 and 30-days was 3.4%, 4.6% and 7.7%, respectively. The model for the clinical impairment indicated that respiratory rate, partial pressure of carbon dioxide, blood urea nitrogen, associated TBI or stroke were risk factors; higher Glasgow Coma Scale (GCS) scores mean a lower risk of impairment. Age, potassium, glucose, prehospital use of mechanical ventilation and concomitant stroke were risk factors associated to mortality; and oxygen saturation, a high score in GCS and haemoglobin were protective factors. Our study shows that prehospital variables could reflect the clinical impairment and mortality of patients suffering from seizures. The incorporation of such variables in the prehospital decision-making process could improve patient outcomes.

Emergency Medical Services Management of Bronchospasm in the United States: A Cross-Sectional Analysis and Nationwide Quality Assessment

Background/Objective: Bronchospasm, caused by asthma and other related conditions, is a significant cause of morbidity and mortality commonly managed by emergency medical services (EMS). We aimed to evaluate the quality of prehospital management of bronchospasm by EMS in the US. Methods: The National EMS Information System Public Release Research dataset, a nationwide convenience sample of prehospital patient care report data from 2018 to 2019, was used to capture 9-1-1 activations where patients aged ≥2 years were treated and transported by EMS for suspected bronchospasm. First, we described the extent to which EMS care met eight quality measures identified from available statewide EMS protocols, existing quality measures, and national guidelines. Second, we quantified the extent of risk-standardized agency-level variation in administration of inhaled beta agonists and systemic corticosteroids using logistic regression models, accounting for patient characteristics, severity, and clustering by agencies. Third, we compared rates of completed prehospital interventions between pediatric (age <18 years) versus adult patients using two-sample t-tests. Results: A total of 1,336,988 EMS encounters for suspected bronchospasm met inclusion criteria. Median age of patients was 66 years, with only 4% pediatric; 55% were female. Advanced life support (ALS) units managed 94% of suspected bronchospasm. Respiratory rate (98%) and pulse oximetry (96%) were documented in nearly all cases. Supplemental oxygen was administered to hypoxic patients by 65% of basic life support (BLS) and 73% of ALS units. BLS administered inhaled beta-agonist therapy less than half the time (48%), compared to 77% by ALS. ALS administered inhaled anticholinergic therapy in 38% of cases, and systemic corticosteroids in 19% of cases. Pediatric patients were significantly less likely to receive supplemental oxygen when hypoxic, inhaled beta-agonists, inhaled anticholinergics, or systemic corticosteroids. Conclusions: We found important gaps in recent EMS practice for prehospital care of suspected bronchospasm. We highlight three targets for improvement: inhaled beta-agonist administration by BLS, systemic corticosteroid administration by ALS, and increased interventions for pediatric patients. These findings indicate important areas for research, protocol modification, and quality improvement efforts to improve EMS management of bronchospasm.

Out-of-Hospital Presentation and Management of Asthma and Chronic Obstructive Pulmonary Disease Exacerbations in the United States: A Nationwide Retrospective Cohort Study.

To describe the demographic, clinical, and emergency medical service (EMS) response characteristics associated with EMS activations for asthma and chronic obstructive pulmonary disease (COPD) exacerbations in the US. Using a nationwide set of out-of-hospital patient care report data from 2018 to 2019, we analyzed 9-1-1 EMS activations where asthma/COPD exacerbation was indicated by symptom, impression, or treatment provided. We excluded patients with ages less than 2 years or unknown, nonemergency transports, and encounters with any indication of anaphylaxis. Demographic, clinical, and EMS response characteristics were described for pediatric and adult patients with asthma/COPD exacerbations. A total of 1,336,988 asthma/COPD exacerbations were included, comprising 5% of qualifying 9-1-1 scene activations from 2018 to 2019. Most patients were adults (96%). Most adult patients were female (55%), whereas most pediatric patients were male (58%). Most activations occurred in urban settings (82%), particularly in pediatric patients (90%). Most asthma/COPD exacerbations were managed by advanced life support units (94%). Inhaled bronchodilators and systemic corticosteroid therapy were administered to 75% and 14% of all patients, respectively. Adults more often had oxygen saturation <92% (43% vs 20% of pediatric patients) and were more often treated with assisted ventilation (9% vs 1%). In this large nationwide sample of 9-1-1 activations treated and transported by EMS, 5% were for asthma/COPD exacerbation. Future work should focus on evidence-based standardization of EMS protocols and practice for asthma/COPD exacerbations to improve the quality of EMS care.

External Validation of Empirically Derived Vital Signs in Children and Comparison to Other Vital Signs Classification Criteria

Objective Various vital sign ranges for pediatric patients have differing utility in identifying children with serious illness or injury requiring immediate intervention. While commonly used ranges are derived from samples of healthy children, limited research has explored the utility of those derived from real-world encounters by emergency medical services (EMS). We first sought to externally validate pediatric vital sign ranges empirically derived from the prehospital setting. Second, we compared the proportion of children who received prehospital interventions using current common classification systems versus empirically derived vital sign ranges. Methods We retrospectively reviewed pediatric (<18 years) prehospital records from the 2021 ESO Collaborative dataset. We compared the proportions of encounters having vital signs (heart rate, respiratory rate, and systolic blood pressure) at the cutoffs of >99th, >95th, >90th, <10th, <5th and <1st centiles to previously reported centiles derived from EMS encounters in 2019–2020. We compared the deviation of mean Z-score by age between data sources. We identified the proportion of encounters with extreme (defined as <10th or >90th centile) vital signs who received prehospital interventions for the empirically derived criteria to six other classification criteria. Results 510,414 encounters were included, of which 66.9% were for medical indications and 70.7% resulted in hospital transport. The study sample had similar proportions of encounters identified at studied cutoffs compared to the previously published derivation sample, with all differences in proportions ≤1.1% between samples. All mean Z-scores were within 0.2 standard deviations of those from the derivation sample for each vital sign. Using empirically derived criteria, 34.2% had at least one extreme vital sign, compared to 69.1% with Pediatric Advanced Life Support criteria. Empirically derived extreme vital signs identified a higher proportion of children requiring most prehospital interventions compared to other vital signs criteria. Conclusion Previously published empirically derived centiles for pediatric prehospital vital signs were replicated in this large multi-agency dataset. Compared to commonly used vital sign ranges, empirically derived criteria identified a higher proportion of children who received key prehospital interventions. Future steps include evaluating the role of these criteria in predictive models for in-hospital outcomes.

93 Patients With Sickle Cell Disease Pain Crises Are Often Undertreated in the Out-of-Hospital Setting: A Multi-Agency Cohort Study

93 Patients With Sickle Cell Disease Pain Crises Are Often Undertreated in the Out-of-Hospital Setting: A Multi-Agency Cohort Study

Epidemiology of Emergency Medical Services Activations for Sport-Related Injuries in the United States

BackgroundLiterature examining emergency medical services (EMS) activations for sport-related injuries is limited to the pediatric, high school, and collegiate student-athlete populations, excluding older individuals and recreational athletes. The purpose of this study was to examine EMS activations for sport-related injuries using the National EMS Information System Database from 2017-2018.MethodsData were obtained using the National EMS Information System Database from 2017-2018. EMS activations were limited to 9-1-1 responses for individuals aged 3-99 who sustained a sports-related injury. Independent variables included patient age group: pediatric (<18 years old) vs. adult (≥18 years old). Dependent variables were patient age, gender, and chief complaint anatomic location. Frequencies and proportions were calculated for each variable. Injury proportion ratios (IPRs) with 95% confidence intervals were calculated to compare chief complaint anatomic location by age group.ResultsThere were 71,322 sport-related injuries. Patients were 36.6±22.9 years and most (58.1%, n=41,132) were male. Adults had higher proportions of injuries affecting the abdomen (IPR: 2.05, 95%CI: 1.83, 2.31), chest (IPR: 1.90, 95%CI: 1.75, 2.05), general/global (IPR: 1.54, 95%CI: 1.50, 1.58), and genitalia (IPR: 2.40, 95%CI: 1.39, 4.15), and lower proportions of injuries affecting the back (IPR: 0.55, 95%CI: 0.50, 0.60), lower extremity (IPR: 0.63, 95%CI: 0.60, 0.65), upper extremity (IPR: 0.50, 95%CI: 0.47, 0.53), head (IPR: 0.73, 95%CI: 0.70, 0.77), and neck (IPR: 0.18, 95%CI: 0.16, 0.20) compared to pediatric patients.ConclusionInjuries sustained differed between adult and pediatric patients, indicating sport-related emergencies may change across the lifespan. General/global chief complaints likely indicate sport-related injuries affecting multiple anatomic locations and organ systems. Stakeholders planning large or high-risk athletic events should consider arranging standby or dedicated advanced life support units for their events.

Opioid administration in the prehospital setting for patients sustaining traumatic injuries: An evaluation of national emergency medical services data

IntroductionDespite concerns about long-term dependence, opioids remain the mainstay of treatment for acute pain from traumatic injuries. Additionally, early pain management has been associated with improved long-term outcomes in injured patients. We sought to identify the patterns of prehospital pain management across the United States. MethodsWe used 2019 national emergency medical services (EMS) data to identify the use of pain management for acutely injured patients. Opioid specific dosing was calculated in morphine milligram equivalents (MME). The effects of opioids as well as adverse events were identified through objective patient data and structured provider documentation. ResultsWe identified a total of 3,831,768 injured patients, 85% of whom were treated by an advanced life support (ALS) unit. There were 269,281 (7.0%) patients treated with opioids, including a small number of patients intubated by EMS (n = 1537; 0.6%). The median opioid dose was 10 MME [IQR 5–10] and fentanyl was the most commonly used opioid (88.2%). Patients treated with opioids had higher initial pain scores documented by EMS than those not receiving opioids (median: 9 vs 4, p<0.001), and had a median reduction in pain score of 3 points (IQR 1–5) based on the final prehospital pain score. Adverse events associated with opioid administration, including episodes of altered mental status (n = 453; 0.2%) and respiratory compromise (n = 252; 0.1%), were rare. For patients with severe pain (≥8/10), 27.3% of patients with major injuries (ISS ≥15) were treated with opioids, compared with 24.8% of those with moderate injuries (ISS 9–14), and 21.4% of those with minor (ISS 1–8) injuries (p<0.001). ConclusionThe use of opioids in the prehospital setting significantly reduced pain among injured patients with few adverse events. Despite its efficacy and safety, the majority of patients with major injuries and severe pain do not receive opioid analgesia in the prehospital setting.

Differences in Out-of-Hospital Cardiac Arrest Management and Outcomes across Urban, Suburban, and Rural Settings

Background Rural prehospital care settings are underrepresented in the out-of-hospital cardiac arrest (OHCA) literature. This study aimed to describe treatment patterns and the odds of a favorable patient outcome (e.g., return of spontaneous circulation (ROSC) or being presumptively alive at the end of the incident) among rural OHCA patients in the U.S. Methods Using the 2018 National Emergency Medical Services Informational System (NEMSIS) dataset, we analyzed OHCA incidents where an emergency medical services (EMS) unit provided cardiopulmonary resuscitation (CPR) and either terminated the resuscitation or completed transport. We excluded traumatic injuries, pediatric patients, and incidents with response time >60 minutes. The primary outcome was ROSC at any time during the EMS incident. The secondary outcome was a binary end-of-event indicator previously described for use in NEMSIS to estimate longer-term outcomes. Multivariable logistic regression was performed for each outcome measure comparing rural, suburban, and urban settings while controlling for key factors. Results A total of 64,489 OHCA incidents were included, with 5,601 (8.9%) in rural settings. Among the full sample of OHCA incidents, ROSC was achieved in 20,578 (33.6%) cases, including 29.2% in rural settings and 34.1% in urban or suburban settings (p < 0.001). Advanced life support units responded to 95.3% of all calls, and a greater proportion of rural OHCA incidents were managed by basic life support units (7.4% vs. 4.2%, p < 0.001). Rural OHCA incidents had longer response times (7.5 vs. 5.9 minutes, p < 0.001), and rural patients were less likely to receive epinephrine (69.3% vs. 73.3%, p < 0.001). Further, EMS clinicians in rural areas were more likely to use mechanical CPR (29.5% vs. 27.6%, p < 0.01) and were less likely to perform advanced airway management (48.5% vs. 54.2%, p < 0.001). Rural patients had lower odds of achieving ROSC than urban patients after controlling for other factors (OR 0.81, 95% CI: 0.75–0.87). Rural patients also had lower odds of having a positive end-of-event outcome (i.e., presumptively alive) after controlling for other factors (OR 0.86, 95% CI: 0.79–0.93). Conclusion In this national sample of EMS-treated OHCAs, rural patients had lower odds of a favorable outcome (e.g., ROSC or presumptively alive) compared to those in urban settings.

Comorbidity-adjusted NEWS predicts mortality in suspected patients with COVID-19 from nursing homes: Multicentre retrospective cohort study.

AimsTo assess the prognostic accuracy of comorbidity‐adjusted National Early Warning Score in suspected Coronavirus disease 2019 patients transferred from nursing homes by the Emergency Department.DesignMulticentre retrospective cohort study.MethodsPatients transferred by high‐priority ambulances from nursing homes to Emergency Departments with suspected severe acute respiratory syndrome coronavirus 2 infection, from March 12 to July 31 2020, were considered. Included variables were: clinical covariates (respiratory rate, oxygen saturation, systolic blood pressure, heart rate, temperature, level of consciousness and supplemental oxygen use), the presence of comorbidities and confirmatory analytical diagnosis of severe acute respiratory syndrome coronavirus 2 infection. The primary outcome was a 2‐day mortality rate. The discriminatory capability of the National Early Warning Score was assessed by the area under the receiver operating characteristic curve in two different cohorts, the validation and the revalidation, which were randomly selected from the main cohort.ResultsA total of 337 nursing homes, 10 advanced life support units, 51 basic life support units and 8 hospitals in Spain entailing 1,324 patients (median age 87 years) was involved in this study. Two‐day mortality was 11.5% (152 cases), with a positivity rate of severe acute respiratory syndrome coronavirus 2 of 51.2%, 77.7% of hospitalization from whom 1% was of intensive care unit admission. The National Early Warning Score results for the revalidation cohort presented an AUC of 0.771, and of 0.885, 0.778 and 0.730 for the low‐, medium‐ and high‐level groups of comorbidities.ConclusionThe comorbidity‐adjusted National Early Warning Score provides a good short‐term prognostic criterion, information that can help in the decision‐making process to guide the best strategy for each older adult, under the current pandemic.Impact What problem did the study address? Under the current coronavirus disease 2019 pandemic, targeting older adults at high risk of deterioration in nursing homes remains challenging. What were the main findings? Comorbidity‐adjusted National Early Warning Score helps to forecast the risk of clinical deterioration more accurately. Where and on whom will the research have impact? A high NEWS, with a low level of comorbidity is associated with optimal predictive performance, making these older adults likely to benefit from continued follow up and potentially hospital referral under the current coronavirus disease 2019 pandemic.